						<fieldset>
							<input type="hidden" value="<?php echo md5(uniqid(rand(), true))?>" name="rid"/>
							<p>
							<label>nome*</label>
							<input type="text" class="text" name="name" id="name" value="<?php echo isset($_POST["name"]) ? $_POST["name"] : "" ?>"/>
							</p>

							<p class="secondo">
							<label>cognome*</label>
							<input type="text" class="text" name="surname" id="surname" value="<?php echo isset($_POST["surname"]) ? $_POST["surname"] : "" ?>"/>
							</p>

							<p>
							<label>email*</label>
							<input type="text" class="text" name="email" id="email" value="<?php echo isset($_POST["email"]) ? $_POST["email"] : "" ?>"/>
							</p>

							<p class="secondo">
							<label>telefono</label>
							<input type="text" class="text" name="phone" id="phone" value="<?php echo isset($_POST["phone"]) ? $_POST["phone"] : "" ?>"/>
							</p>
							
							<p>
							<label>scuola/facolt&agrave;</label>
							<input type="text" class="text" name="school" id="school" value="<?php echo isset($_POST["school"]) ? $_POST["school"] : "" ?>"/>
							</p>

							<p class="secondo">
							<label>classe/anno</label>
							<input type="text" class="text" name="classroom" id="classroom" value="<?php echo isset($_POST["classroom"]) ? $_POST["classroom"] : "" ?>"/>
							</p>
							
							<div class="pulizia"></div>
							<p class="note">i campi contrassegnati da (*) sono obbligatori</pre>

							<div class="separatore"></div>
							
							<h4>segnalazione</h4>

							<p>
								<label>indirizzo*</label>
								<input type="text" class="text" name="report_address" id="report_address" value="<?php echo isset($_POST["report_address"]) ? $_POST["report_address"] : "" ?>"/>
							</p>

							<p class="secondo">
								<label>n. civico*</label>
								<input type="text" class="text" name="report_number" id="report_number" value="<?php echo isset($_POST["report_number"]) ? $_POST["report_number"] : "" ?>"/>
							</p>

							<p>
								<label>CAP*&nbsp;&nbsp;&nbsp;<a href="http://www.poste.it/online/cercacap/" target="_blank">[puoi cercarlo qui]</a></label>
								<input type="text" class="text" name="report_zip" id="report_zip" value="<?php echo isset($_POST["report_zip"]) ? $_POST["report_zip"] : "" ?>"/>
							</p>
							
							<p class="secondo">
								<label>tipo segnalazione*</label>
								<select class="text" name="report_type" id="report_type">
									<option value="">-</option>
							        <option value="3"<?php echo ($_POST["report_type"] == '3') ? " selected=\"selected\"" : "" ?>>segnalazioni per problemi legati al manto stradale</option>
							        <option value="2"<?php echo ($_POST["report_type"] == '2') ? " selected=\"selected\"" : "" ?>>segnalazioni per problemi legati alla segnaletica</option>
							        <option value="1"<?php echo ($_POST["report_type"] == '1') ? " selected=\"selected\"" : "" ?>>segnalazioni per problemi legati ai semafori</option>
								</select>
							</p>

							<p class="area">
								<label>descrizione situazione di pericolo*</label>
								<textarea class="textarea" name="report" id="report"/><?php echo isset($_POST["report"]) ? $_POST["report"] : "" ?></textarea>
							</p>

							<p>
								<label>allega immagine</label>
								<input type="file" class="file" name="report_photo" id="report_photo"/>
							</p>
								
							<div class="pulizia"></div>
							<div class="separatore"></div>
							
							<h4>inserire codice di sicurezza</h4>

							<p class="captcha">{imageverification}</p>
							
							<div class="pulizia"></div>
							<div class="separatore"></div>
							
							<h4>iscrizione alla newsletter</h4>

							<p class="accetto">
								<strong>iscrivimi</strong>
								<input type="radio" name="newsletter" id="newsletter-valid" value="1"<?php echo !isset($_POST["newsletter"]) || $_POST["newsletter"] ? " checked=\"checked\"" : "" ?>/> <label for="agree-valid">s&igrave; </label>
								<input type="radio" name="newsletter" id="newsletter-invalid" value="0"<?php echo isset($_POST["newsletter"]) && !$_POST["newsletter"] ? " checked=\"checked\"" : "" ?>/> <label for="agree-invalid">no</label>
							</p>
														
							<div class="pulizia"></div>
							<div class="separatore"></div>
							
							<h4>normativa sulla privacy</h4>

							<p class="area">
								<textarea class="textarea"/>{loadposition privacy}</textarea>
							</p>

							<p class="accetto">
								<strong>accetto</strong>
								<input type="radio" name="agree" id="agree-valid" value="1"/> <label for="agree-valid">s&igrave; </label>
								<input type="radio" name="agree" id="agree-invalid" value="0"/> <label for="agree-invalid">no</label>
							</p>

							<p class="secondo">
								<button type="submit">invia</button>
							</p>
														
						</fieldset>